FRAME RELEASE ACKNOWLEDGEMENT Dear Patient, We are happy to make new prescription lenses for your own frame or new frame bought elsewhere. We pledge to take the utmost care in handling it. In a small percentage of cases, the frame material will not be up to the standard needed to insert prescription lenses or be worn or brittle due to age. Eye Symmetry Vision IS NOT responsible for any cracks, defects, scratches or stress marks caused by the process of removing old lenses or insertion of new prescription lenses. If your frame breaks during the insertion process, we will make new lenses at no charge for any new frame you choose, but the cost of the replacement frame is your responsibility. If this frame is being sent to your vision insurance company’s lab it is your responsible to know your insurance company’s policy for using old frames or frames not purchased at Eye Symmetry Vision and you accept that your insurance company’s policy applies. Eye Symmetry ask that you please inspect your glasses before leaving the office. Once you leave Eye Symmetry is not liable in any way for any breakage or damage. Your signature is required and acknowledges that you understand and accept these statements. Patient Signature(Required)Print Name(Required) First Last Date(Required) MM slash DD slash YYYY Frame NameManufacturer(Required)ColorSize(Required) Δ
